Signs and Symptoms
People
with schizophrenia experience many different types of symptoms (Hyman, 2007). Positive symptoms are behaviors that are
not evident in healthy people. Negative(deficit)
symptoms reflect an absence of behaviors that are usually evident in
healthypeople. Cognitive symptoms
reflect impairments in executive functions such as working memory and
attentional control and can include the state of psychosis, or loss of contact with reality, so that the beliefs and
perceptions of someone with schizophrenia are often extremely bizarre (Figure
16.19). Here is one account of what it feels like to have schizophrenia:
When
my first episode of schizophrenia occurred, I was 21, a senior in college in
Atlanta, Georgia. I was making good grades, assistant vice president of my in
my sorority, president of the Spanish club, and very popular. Everything in my
life was just perfect. . . .
All
of a sudden things weren’t going so well. I began to lose control of my life
and, most of all, myself. I couldn’t concentrate on my school-work, I couldn’t
sleep, and when I did sleep, I had dreams about dying. I was afraid to go to
class, imagined that people were talking about me, and on top of that I heard
voices. I called my mother in Pittsburgh and asked for her advice. She told me
to move off campus into an apartment with my sister.
After
I moved in with my sister, things got worse. I was afraid to go outside and
when I looked out of the window, it seemed that everyone outside was yelling
“kill her, kill her.” My sister forced me to go to school. I would go out of
the house until I knew she had gone to work; then I would return home. Things
continued to get worse. I imagined that I had a foul body odor and I sometimes
took up to six showers a day. I recall going to the grocery store one day, and
I imagined that the people in the store were saying “Get saved, Jesus is the
answer.” Things worsened—I couldn’t remember a thing. I had a notebook full of
reminders telling me what to do on that particular day. I couldn’t remember my
schoolwork, and I would study from 6:00 p.m. until 4:00 a.m., but never had the
courage to go to class on the following day. I tried to tell my sister about
it, but she did-n’t understand. She suggested that I see a psychiatrist, but I
was afraid to go out of the house to see him.
Positive
symptoms—behaviors that are not evident in healthy people—can take several
forms. People with schizophrenia typically suffer from delusions—incorrect beliefs that are rigidly maintained despite the
absence of any evidence for the belief, and, in many cases, despite
contradictory evidence. By one estimate, 90% of all
patients
with schizophrenia suffer from delusions (Cutting, 1995). Thus a patient with
schizophrenia might be convinced he is Moses, or the king of England, or a
special messenger from God. Likewise, people with schizophrenia often believe
that their thoughts or actions are being controlled by someone else (by space
aliens, for example, or by the CIA; Figure 16.20). Sometimes they believe their
thoughts are being broadcast (and so are fully audible) to other people. Delusions of reference are also common,
in which the patient is convinced that some neutral environmental event is
somehow directed at her. For example, a patient might observe two strangers
talking and be certain they are talking about him; she sees some people walk by
and decides they are following her; he sees a television commercial and is sure
it contains a secret message aimed only at him.
A
second type of positive symptom is hallucinations—sensory
experiences in the absence of any actual input. Most common in schizophrenia
are auditory hallucina-tions, and, in particular, voices. Thus, the patient
might “hear” the voice of God, or the devil, or a neighbor. If the patient can
make out what the voices are saying, she will often report that they are
talking about her, shouting obscenities at her, threatening her, or telling her
what to do. Researchers have explored these hallucinations via func-tional
brain imaging and have documented increased brain activation, during the
hallucinations, in primary auditory regions in the temporal lobe (Lennox, Park,
Medley, Morris, & Jones, 2000). This finding suggests that when people with
schizophrenia have auditory hallucinations, they are hearing voices that sound
every bit as vivid and real to them as actual voices.
Positive
symptoms also may take the form of unusual behaviors. People with schizophrenia
sometimes dress peculiarly (wearing layers of warm clothing on a hot day) and show
disorganized behavior, becoming
frenzied, running haphazardly, shouting nonsensically, and acting violently
(Figure 16.21). In many ways, the disorganized behavior associated with
schizophrenia is the closest match to the popular stereotype of madness: A
person who has schizophrenia may have speech that is bizarre and babbling, and
while he is talking, he may giggle, make silly smiles or odd grimaces, assume
odd postures, and have sudden fits of laughing and crying.
In
addition to positive symptoms, people with schizophrenia may show several types
of negative symptoms. One negative symptom is a flattening or cessation of
behavioral responses. For example, someone with schizophrenia may express
little emotion, may say relatively little, and may be unable to persist in many
activities. People who have been ill for a long time will often stare vacantly
into space, their faces expressionless, and, if they answer questions at all,
they do so in a monotone. At the extreme, individ-uals with schizophrenia may
show catatonic behavior, standing or
sitting “frozen” for hours on end, sometimes in unusual postures (Figure
16.22).
A
second type of negative symptom is anhedonia, the loss of interest in
activities that we would ordinarily expect to be pleasurable. People with
schizophrenia also seem not to anticipate pleasure in the way that healthy
people do, a finding that corresponds with lower levels of goal-oriented
behavior (Gard et al., 2007).
A third negative symptom—which may be related to the failure to anticipate pleasure— is withdrawal from other people (Tarbox & Pogue-Geile, 2008). In some patients, this with-drawal begins quite early, with a history of few childhood friends and limited adolescent social contact. In others, the individual gradually develops an inner world that becomes more and more private and less and less involved with the social world. As a result, the thoughts of this person become ever more idiosyncratic, until she may have trouble communicating with others even if she wants to. This situation makes it even more likely that others will rebuff her because they cannot understand her and think she is “weird.” The vicious cycle of rejections can lead to further withdrawal and idiosyncrasy.
People
with schizophrenia often display marked cognitive difficulties. They seem
unable to maintain a coherent train of thought, but rather skip from one idea
to the next, and this typically shows up in their speech. An example is a
fragment of a letter written by one of Bleuler’s patients. The writing starts
out normally enough, but then deteriorates:
I
am writing on paper. The pen I am using is from a factory called “Perry &
Co.” This factory is in England. I assume this. Behind the name of Perry Co.,
the city of London is inscribed; but not the city. The city of London is in
England. I know this from my school-days. Then, I always liked geography. My
last teacher in that subject was Professor August A. He was a man with black
eyes. I also like black eyes. There are also blue and gray eyes and other sorts
too. I have heard it said that snakes have green eyes. All people have eyes.
There are some, too, who are blind. These blind people are led about by a boy.
It
is also common for people with schizophrenia to have significant impairments
start-ing with the earliest stages of sensory processing (Walker, Kestler,
Bollini, & Hochman, 2004) and extending through episodic memory and
cognitive control (Reichenberg & Harvey, 2007). Other perceptual and motor
abnormalities are evident in people who have not been diagnosed with
schizophrenia but who are at elevated risk for the disease; these abnormalities
include deficits in two-point discrimination (distinguishing between 1 and 2
points touching the skin) and simple line drawing (Lenzenweger, 2006). These
(and other) cognitive problems may all contribute to the broad pattern of
symptoms that are typical of schizophrenia. An inability to inhibit thoughts
and actions, for example, con-tributes to disrupted speech and behavior, while
difficulties in executive function interfere with the ability to reason and so
foster the delusions.
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